ENDOCRINOLOGY H+E (OBESITY)
OBESITY [eating habits + psychology + underlying co-morbidity]
GENERAL: fatigue è fever/swelling/rash è sleep (OSA – insomnia)/weight gain/loss
Eating Disorder Medical Cause of weight gain
• EATING HABITS: Over-nutrition (too many • Endocrine = PCOS, Cushing’s, Hypothyroidism
meals) + Previous diets + regularity of eating + • CV = HTN HF, IHD, PE and CAD
food groups
• MSK = OA, immobility, Turner’s, achondroplasia
o Do you worry about your weight?
• Resp = OSA
o How do you feel about your weight?
o Do you diet? or What other things Definition DSM-V Criteria Complications
have you tried to control your weight? • OP (dexa scan)
o Have you made yourself sick after • Sinus
meals? Skip meals? Where do you 1. Restriction of energy intake bradycardia
excessive
go after meals – toilet? • Hypothermia
dieting 2. Intense fear of gaining weight;
Anorexia
• Weight Hx followed by 3. Disturbance in body image • HypoTN
1. HPS • Mood (risk of self-harm)
nervosa
vomiting or (cannot recognise seriousness of • Low
purging the current low body weight) electrolytes –
• Feeling about food (reasons for avoiding food)
arrythmia
• Physical signs of anorexia nervosa
• Depression
o Cold dizzy, weak, thin hair
1. Recurrent episodes of binge • Mallory-weiss
o Reduced libido eating (excess food consumed tear
o Menstrual changes (amenorrhoea – AND a sense of lack of control) • Oesophagitis
central / functional cause) Frequent binge 2. Recurrent inappropriate
eating • Depression
o Postural drop, bradycardia compensatory behaviours (e.g.
Bulimia followed by • Altered
vomiting, fasting excessive
o Hypothermia nervosa vomiting or electrolytes
exercise)
o Electrolyte abnormalities purging
3. Frequency of at > 1x /every 3/12
[compensatory]
o QTc > 450ms 4. Self-evaluation unduly influenced
by body shape and weight
5. Absence of anorexia nervosa
Conditions • MetSyn: HT, hypercholesteroleamia, diabetes (hyperinsulinemia),
• GORD, PCOS
Previous surgeries • Previous bariatric surgery ® risk of:
o Vitamin def. – oral B12, folate
o Anaemia – oral Fe
o OP
2. PMHx o Regain weight (bad habits)
o Marjolin ulcers ® PPI
Medications Gain weight = COCP, anti-depressants, anti-psychotics, corticosteroids
Tests (exploratory Fasting BGL (HbA1C), blood tests, Ultrasound (PCOS)
Allergies & Vaccinations strep. Pneumoniae, FluVax
• Background: Thalassaemia (Mediterranean/South Asian), sickle cell disease (Africans)
• Occupation: sedentary
3. SHx • Lifestyle: diet restrictions/regularity + physical activity
• Smoking/Alcohol/Drugs
• Overseas travel (malarial infection or intestinal parasitic)
• 1st degree relatives with CV risk factors (i.e. obesity, stroke, HF)
4. FHx • PCOS (strongly inherited)
• CNS, MSK: joint pain/aches, muscle pains/aches, muscle tremor, muscle wasting, LOC
5. SR • CVS – [chest pain] CAD SPIFE, RESP – [shortness of breath] SCSC FAWIF
• GU – dysuria? Vaginal discharge? | menstrual cycle for 20-50s (menorrhagia – bleeding) | menopause > 50
Examination Procedure
• General: baggy clothing, peripheral cyanosis
• Hands è dry skin, brittle nails + skin turgor (dehydration), dorsal finger callous (Russell’s sign),
Peripheral lanugo (hair growth)
signs • Mouth è fruity breath (ketosis – starvation state = AN), dental enamel erosion (purging), gingivitis,
• Head & neck è parotidomegaly, xerosis (dry mouth, eyes and skin)
• Legs – Swelling (oedema), capillary refill time (<3s)
• Measurements: Height, weight, BMI
• CV: Bradycardia, Hypotension (+postural), Hypothermia
Examination o Long QT syndrome (hypokalaemia)
o Reduced cardiac contractility (hypoPO4)
• MSK: squat test (muscle power) – Gower’s sign
, GENERAL ENDOCRINE + DIABETES H+E
NEURO/CNS • Headaches [SOCRATES], vision issues (bitemporal hemianopia) è [pituitary tumour] – foot drop, carpul tunnel
CV • Chest pain [SOCRATES]
[CADSPIF] • palpitations, diaphoresis, swelling in leg [CLAUDICATION]
RESP • SOB (dyspnoea, PND, Orthopnoea), OSA (snoring)
[SCSC] • Cough ® sputum?
GI • Nausea + Vomiting (how much?) | Bowel habits (constipation | diarrhoea)
[BLIND CRAP] • Abdominal Pain [SOCRATES] + Abdominal bloating
Renal • Polyuria/Nocturia, Polydipsia ® postural hypotension, electrolyte loss
[FUNDWISE] • UTIs & Urethra discharge
• ♀: Irregular cycles / Period volume Menorrhagia (pain/volume) / Galactorrhoea / infertility
Gynae
• ♂: ED / gynaecomastia / loss of libido / infertility
• Hyperpigmentation OR Bruising • Rashes + Redness
Skin
• Hair (loss or excess growth)
• Muscle tremor • Muscle wasting
MSK
• Fractures/Bone pain • Joint pain
General • Fever | Unintentional Weight gain/loss | Appetite | Sleep (insomnia, very sleepy)
Excess GH Excess TSH Excess ACTH Excess LH/FSH Excess Prolactin
IGF-1 T3/T4 Aldosterone & cortisol & androgens (TT) Estrogen & testosterone PrL levels
Effects of aldosterone:
• Polyuria
• Physically bigger • Neck lump • Low renin-aldosterone ratio Females: • Galactorrhea
(cannot wear • “Anyone comment • Hypernatremia, hypokalemia ® arrhythmia • Increased muscle ( prolactin )
wedding ring) about eyes” • Met. Alkalosis mass • Amenorrhea
• Dysphagia • Weight loss • Hypertension ® Na+ water retention • Increased libido & irregular
(closure of (Increased
metabolic rate) • Heavy menses menses
oesophagus)
Effects of cortisol: • Hirsutism (LH/FSH
• Hoarseness • SOB (RR)
• Circadian rhythm ® cognitive, mood, memory • Ovulation suppressed)
(compress vocal • Diarrhoea
folds) • Stress: • Vaginal secretion = • Gynecomastia
( GI motility)
o Liver: GGN, GNG ® hyperglycemia ® vaginal dryness ( prolactin )
• Arrythmias • Hypertension +
weight loss • ¯ osteoclast = • Loss of libido
• Snoring (OSA) tremor
o Muscle: Proteolysis ® cachexia fracture • ED
1. History of • Skin tags + ( contractility +
acanthosis nig. o AT: lipolysis ® weight loss • Infertility
presenting HR)
• BP = BV vasoconstriction Males:
complaint • Bone pain (excess • Hyperglycemia
bone growth) • ¯ immune system = ¯ inflammation ( • spermatogenesis
[Think Systems] • Sweaty Warm skin Rx: cabergoline
• Sweaty warm infection) • Increased libido (+
(Increased (dop. Agonist)
palms • osteoclasts = osteoporosis erection)
metabolic rate)
• ¯ GnRH = ¯ androgens = irregular menses and
infertility + ¯ libido
Acute Hyperglycemic (>15mm) Acute Hypoglycemic (<3.5mm)
• Polyuria & Unintentional Weight • Sweating,
Suspected • Dehydrated (Polydipsia) • Fainting,
• Blurred Vision (Lens Shape Change) , • Paraesthesia,
T2DM
• Fatigue • Visual Disturbances,
• Recurrent Infections • Tremor,
• DKA Or HHS Admission (If Severe) • Decreased Awareness (If Severe, Need Paramedics)
When? How? What Type?
Diagnosed
Prediabetes = IGT/IFT + Diabetes è 25% of hospital admission doubles hospital stay time
• Recent Hba1c, BSL Trend (Vs Hx) ® Regular Checks? è • Hypoawareness (Asymptomatic)
Target ≤ 6.5% • Specific Patterns (Fasting Vs Post-Prandial)
Management & • Test Method: HBGM, CGMS (T1DM)?
Compliance • Methods of administration: flexipen, injection,
• # Of Admissions (E.G. DKA, Hypoglycemia) insulin pump [convenience, cost, lifestyle, preference,
• MDT (Endocrinologist, Optometrist, GP, Carers tech advancement
Microvascular • Neuropathy (Feet Paraesthesia & Shooting Pain + Ulcers + Recurrent Infection)
[Damage to • Retinopathy (long-term ® Blurred Vision, Myopia Cataracts, Glaucoma – Intraocular Pressure)
smaller BVs] • Nephropathy (Polyuria/Nocturia, Proteinuria, Glycosuria) + Polydipsia (flow/colour/hesitancy)
Macrovascular • CV – HTN (Chest Pain On Rest/Exertion, Previous MI) è Previous Stents, ECGs
Damage to larger • TIA/Stroke
BVs • PVD (Claudication + Repeated Distance ® Unilateral/Bilateral)
• Female: Utis, Vaginal Thrush
Other • Autonomic: Gastroparesis, ED (issues with erection, atypical silent MI (High Risk For Coronary Heart Disease Esp. >50)
• General: Fever, Weight Gain/Loss, Appetite, Sleep
• Hypertension (possible pheo, Cushing’s or Conn’s).
• Vascular Risk: BP, Lipids (HC) è Patients With Metsyn = 2x Risk Of CVD And 5x Risk Of T2D
Conditions
• Metabolic Risk: PCOS/GDM, Gout, OSA, Thyroid Disease, Non-Alcoholic Hepatic Steatosis, NAFLD
• Previous Hx: endocrine condition , existing autoimmune (e.g. coeliac)
2. Past MHx • antithyroid drugs, thyroid hormone or radioactive iodine
[CHOMV STAVE] • HRTs (e.g glucocorticoids -prednisone for asthma, estrogen ® menopause)
Medications
• antiarrhythmic drug amiodarone (contains iodine ® commonly causes hypo- or hyperthyroidism)
Surgeries/ • partial thyroidectomy ® leads to hypothyroidism AND hypoparathyroidism (damage to PTH glands)
Treatments • Surgery on the adrenals or pituitary è decreased adrenal or pituitary function
• IV contrast
• Occupation/study: stressful jobs
3. Social Hx o Moderate alcohol = hyperglycaemia
o Binge drinking ® hypoglycaemia
1. Autoimmune diseases (E.g. Grave’s, hashimoto, pernicious anaemia, coeliac è link with T1DM)
4. FHx 2. 1st deg. Relatives with CV-related death < 50.
3. FHx of diabetes, multiple-endocrine neoplasia (MEN) + CV risk factors,
, Thyroid Gland Examination
Summary:
• Today I conducted a thyroid examination on _____, a ____ year-old male.
• On general inspection, he had ____ (any tremors, redness, temperature, sweaty) with no other peripheral signs of thyroid disease
• There was NO? evidence of thyroid eye disease and no goitre
• To complete the examination, I would like to conduct some blood tests looking specifically at the TSH and T4 levels
Exposure This will involve me generally inspecting before me moving in closer to look and feel the thyroids in the neck.
General • Weight | Anxiety | fidgety è hyperthyroidism | mental/physical sluggishness è hypothyroidism
• hypothyroidism =PUFFY WRISTS/Cool/ dry palms è bradycardic è palmor crease pallor
Hands/Wrist • hyperthyroidism [SNS overactivity] = Sweaty/palmar erythema/ Peripheral tremor/tachycardic or AF/ irregular
[arms out ] pulse
[paper + pulse] onycholysis
o Grave’s disease = clubbing (thyroid acropachy)
Peripheral Arms • ARM/LEG: Biceps or knee reflex = hyporeflexia (hypothyroidism)
signs • hypothyroidism = dry and cool skin | loss of outer 3rd eyebrow or thinned eyebrows
Face
• hyperthyroidism = excessive sweating
Eyes • Grave’s disease: bilateral exophthalmos (bulging eyes = LOOK FROM SIDE)
Look from o NB: Upper eyelid retraction (SCLERA VISIBLE) = ANY form of thyrotoxicosis
side/behind • H-TEST = diplopia/ ophthalmoplegia (e.g. restricted eye movement) & pain during eye movement
[H-TEST] • Move finger up/down = Upper lid lag [von Graefe’s sign]
• Masses è Pseudogoitre (excess fat pad = obese) OR Goitre = outward bulge [80% euthyroid, 10% hypo nd 10% hyper]
Inspect • Scars: thyroidectomy scar
Thyroid • Erythema (suppurative thyroiditis)
[swallowing & • Prominent veins upper chest wall è thoracic inlet obstruction
tongue • Pemberton’s sign è SVC obstruction
protrusion] • Swallow Water, and watch neck swelling during swallowingè Mass rises? = goitre, thyroglossal cyst,
• Stick tongue Out Mass rises? Yes = thyroglossal cyst, No = thyroid gland mass, lymph node
For any nodule/swelling: Size | Shape (symmetry) | consistency | tender (thyroiditis) | mobility [repeat swallowing]
• Soft (but firmer than a fat pad) = NORMAL
• Firm = simple goitre
Palpate lobes
• firm and tender gland = de Quervain’s thyroiditis
and isthmus
• rubbery hard = Hashimoto’s thyroiditis
(from behind • stony, hard node = carcinoma | calcification in a cyst |fibrosis
then front x2) Patient flex neck to relax SCM
• Lymphadenopathy (all lymph nodes) è palpate using pads of 2nd, 3rd, 4th fingers
• Tracheal deviation (large goitre)
Percuss Sternal notch è change from resonant to dull è retrosternal goitre (extends inferiorly BUT unreliable sign)
• Listen over each lobe for a bruit è specific sign of increased blood supply for Grave’s)
Auscultate
• Retrosternal goitre/mass compress lateral lobes è Stridor è thoracic inlet obstruction
• ARM: arms crossed + stand up è proximal myopathy, (multinodular goitre & Grave’s)
SPECIAL
• LEGS: Rolls pants up è pretibial myxoedema (rare for Grave’s disease) = bilateral firm, elevated dermal nodules and plaques [pink, brown or
TESTS skin coloured] due to mucopolysaccharide accumulation (glycosamioglycans)
